Please make sure when your taking a photo that it's not blurry because we need to be able to see your ID photo and the date when it expires.
Whether you’re entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
(This form is not valid unless you sign it
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
All information entered on this form is considered to be offered as a sworn statement. Any misstatement of fact is reason for disqualifi cation for employment, or may be punishable by law as per N.J.S. 2C:28-2, 2C:28-3 and 2C:28-7.
No person shall be employed by any holder of a security agency license until such person to be employed shall have executed and furnished to such license holder the following statement, pursuant to the provisions of “The Security Offi cer Registration Act (SORA)” as amended by Chapter 134, Laws of 2004.
The statement must be made in the handwriting of the person to be employed by the licensed security agency and must be retained by the security agency.
2.Give your business or occupation engaged in for the fi ve years immediately preceding the date of the fi ling of this statement with your employer, setting forth the place or places where such business or occupation was engaged in and the name or names of employers, if any, with dates thereof:
(Name of Person Making This Statement)
being duly sworn, deposes and says: that he is the person above named; that he has read the foregoing statement and the answers thereon noted; that such answers are true to his knowledge, and that he personally attached his signature to this af- fi davit; that the above answers were written in the handwriting of deponent.